Rheumatology and

Musculo-skeletal Clinic


Manipulative Therapy

Manipulation techniques have been around for millennia.  In more modern times, osteopaths, chiropractors, and some physiotherapists have used manipulative therapies with varying degrees of success.  While most people will develop some form of back pain in their life-time, only 20% of those people will go on to have a chronic injury.  Some of those people will need mobilization or manipulative techniques to release dysfunctional joints.

Why is manipulation or mobilization used?  Manipulation is used to release joints that have become stuck.  An immobile, or dysfunctional joint causes surrounding spasm of muscles that leads to chronic pain.  These injuries have been described as acute and chronic back pain, neck pain, lumbar pains, and sacro-iliac pains (or variants that radiate pain down the leg known as forms of sciatica).  A variation on the theme is known as fibromyalgia syndrome - defined by the presence of multiple soft tissue ‘trigger points’ in predefined areas.  These trigger points most commonly, in the experience of this clinic’s physicians, come from joint dysfunction in the spine.  Treating the joint dysfunction frequently eliminates the ‘fibromyalgia syndrome’.

How can one tell if a joint has become ‘stuck’?  Plain X-rays do not show joint dysfunction on most views.  The only way a plain X-ray can show the dysfunction is by doing flexion and extension views of the neck.  When these lateral views are overlaid, and motion is looked for, between each pair of dorsal spinous processes (the knobs of spine you can feel when running your hand down the back), the presence or absence of movement can be assessed.  A badly stuck joint will have no movement at all between flexion and extension. 

An analogy to this is the old fashioned drawer (that did not run on rollers).  When the drawer became loose, and a sideways motion was applied to the drawer as it was pushed in, it became stuck.  No matter how hard one pushed, the drawer would not move.  The stuck drawer could only be released by pulling backwards or in the opposite direction to the side on which it was stuck. 

Manipulative techniques involve the same process as releasing the stuck drawer, either a straight stretch, or a short sharp movement in the opposite direction to which the joint is stuck.  A test manipulation is more sensitive than X-rays for finding stuck or dysfunctional joints.  MRI (magnetic resonance imaging) is no more useful than X-rays at finding dysfunction.

Are there any side-effects?  There are few side-effects.  About 1% of people will have the muscles go into acute spasm following manipulation or mobilization.  This usually settles down in a few minutes.  Acute injuries usually have too much spasm to be released, and in this situation, it is advised that the patient take some form of analgesia or anti-inflammatory medication, while waiting for time to settle the acute process.  (Check with your doctor before taking any medications.  Some medications are not suitable for some people.)  A very small risk for a stroke syndrome exists when manipulating the neck.  Depending on the study, the risk for stroke or vertebral artery dissection (where the inside lining of the rear arteries feeding the brain are split), is said to range between 1:50,000 and 1:5,000,000, with the average being about 1:1,000,000.  So far no patients at this Clinic have suffered a stroke from the manipulative techniques used.

How well does the treatment work?   Manipulation or mobilization alone will only provide long-term relief in about 30% of patients.  This is because the healing process has become exhausted and no further strengthening of the damaged ligament will happen after 6 months following the original injury.  However, by combining manipulation with prolotherapy to stimulate the healing process to strengthen the damaged ligaments, the success rate increases to around 90%.*